Exenatide is a GLP-1 analogue used in the management of T2DM yet within a subset of patients fails due to adverse side effects or from failure to attain the end goal. This retrospective observational study aimed to determine whether we could predict response to exenatide in patients with T2DM. 112 patients on exenatide were included with patient age, gender, duration of T2DM, medications alongside exenatide and weight, BMI, and HbA1c at baseline and 3 and 6 months of exenatide use being recorded. 63 responded with 11 mmol/mol reduction from baseline HbA1c after six months and 49 did not respond to exenatide. HbA1c solely differed significantly between cohorts at baseline, 3 months, and 6 months (P < 0.05). Regression analyses identified a negative linear relationship with higher baseline HbA1c correlating to greater reductions in HbA1c by 6 months (P < 0.0001). HbA1c was the sole predictor of exenatide response with higher baseline HbA1c increasing the odds of response by 5% (P = 0.004). Patients with HbA1c reductions ≥15–20% by 3 months were more likely to be responders by 6 months (P = 0.033). Our study identified that baseline HbA1c acted as the sole predictor of exenatide response and that response may be determined after 3 months of exenatide administration.

Postural Tachycardia Syndrome (PoTS) represents a disorder of the autonomic nervous system that results in symptoms of orthostatic intolerance. Despite having a severe impact on the patient's quality of life, the current treatment options for PoTS are based on limited evidence. Subsequently, this results in clinicians having to utilise a variety of treatment regimens in the hope of successfully providing symptomatic relief. However, the options available for PoTS are not without significant side effects that can worsen an already debilitating condition. Our cases provide a further novel treatment option for clinicians to consider in PoTS refractory to established treatments.

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Patients may benefit from the possible effects of AcH on their bowels, and assessment of all aspects of pelvic floor function is important before commencing AcH. This may help to counsel patients, with possibly improved compliance with therapy.

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• A 22 year old female presented in April 2002 with five episodic bouts of self-remitting palpitations, each lasting thirty seconds, over a period of four months.• Each episode was associated with chest discomfort, dyspnoea and dizziness.• Patient denied experiencing nausea, diaphoresis or syncope.• The patient had no significant medical or surgical history.• The patient was not taking any prescribed or over the counter medications.• Patient reported no history of such a presentation within the family and no significant family medical conditions. Clinical Course• Initial systemic examination revealed nothing of note par a regular resting heart rate of 99 beats per minute (bpm).• Patient underwent a series of investigations which included full blood count, urea, electrolytes, thyroid function tests, 5 day Holter monitoring, chest X-ray, cardiomemo, electrophysiological studies and an echocardiogram.• Despite such an exhaustive list of investigations, the only finding of note was sinus rhythm alternating with sinus tachycardia on Holter monitoring.• Over a period of 3 years since initial presentation, her symptoms had escalated to the point where :• She was forced to become wheelchair bound due to the severity of her orthostatic symptoms • She was now experiencing multiple syncopal episodes resulting in long bone fractures • She was forced to withdraw from her medical training • Her declining quality of life left her clinically depressed• In 2005, after 3 years of inconclusive studies, the patient underwent Tilt Table Testing (TTT).• TTT revealed four pre-syncopal episodes associated with a sinus tachycardia and decrease in BP; maximum rise in heart rate of 42bpm and minimum BP recorded being 103/92mmHg.• TTT confirmed a diagnosis of PoTS which was later confirmed using autonomic testing (Table 1). Discussion• PoTS reflects a dysfunction of the autonomic nervous system leading to several debilitating features.• Clinically, PoTS is defined by a sustained rise in heart rate of ≥30bpm or an increase in heart rate to ≥120bpm within 10 minutes on movement from supine to an upright position 2 .• Although several pharmaceutical options exist, one therapy includes the use of the somatostatin analogue octreotide 3 (Figure 2).• Octreotide acts as a somatostatin analogue, binding with high affinity to the somatostatin receptor subtypes 2 and 5 4 .• Its proposed efficacy in PoTS centres on its ability to stimulate vasoconstriction in the systemic and splanchnic vasculature, thereby increasing venous return 5 .• Despite SC and intramuscular long acting release (LAR) preparations being efficacious, the side effects, cost and inconvenience of frequent injections makes them far from ideal 5 .• Our case highlights how delivery of SC octreotide via an Animas insulin pump provides a novel mode of delivery of therapy for PoTS, whereby a lower dose can be given with fewer undesired effects. • Fludrocortisone -300µg OD • Slow Sodium MR -600mg up to 10 times a day • Midodrine -5mg TDS • Ivabradine -7.5mg BD• All therapies mentioned abov...

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